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HLTAP Arteriosclerosis

VIEWS: 54 PAGES: 18

									Electrolyte and fluid balance


1. Body fluids are distributed between compartments. Describe
these compartments and their percentage of total body weight.
The compartments are the intracellular compartment and the extracellular
compartment.
The intracellular compartment has trillion of individual compartments, the
cells, which consist of fluid.
Extracellular, is the fluid outside the cells and consists of 2 sub
compartments, which are the plasma and interstitial fluid.
40% of the body weight is intracellular for males and 35% for females.
20% of body weight is extracellular, which is made up of 80% interstitial
fluid and 20% plasma volume.
(Marieb. E, 2007)


2. Define an electrolyte.
An electrolyte, either element or compound, is a medium that cond ucts
electricity. Electrolytes include sodium, chloride, potassium and calcium
and when dissolved in water or another substance, will separate or split
into ions and then able to conduct an electric current.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


3. Body fluids are maintained at a constant level by several
homeostatic mechanisms.
      Osmosis
   Osmosis is the movement of a solvent, such as water, across a
   semipermeable membrane from a solution that has a low solute
   concentration to one that has a higher solute concentration.
      Diffusion




                                                                             1
   Diffusion is a process where particles within a substance, move from
   an area of high concentration to one of a low concentration.
      Active transport
   Active transport is the movement of particles or ions across a cell
   membrane against a concentration gradient, an area of low to high
   concentration, which requires the use of energy.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


4. Which is the most important electrolyte for the maintenance of
osmotic pressure and volume in the extra cellular fluid (ECF)
compartment.
The most important electrolyte for the maintenance of osmotic pressure
and volume in the ECF compartment is Sodium
(Marieb. E, 2007)


5. Which is the main intracellular ion that maintains intracellular
fluid osmotic pressure?
The main intracellular ion that maintains intracellular fluid osmotic
pressure is potassium.
(Marieb. E, 2007)


Integumentary System


Mary who is 94 years old has been put in a bath with water that was
too hot and has received burns to 36% of her body of varying
depths.
6. Why is dehydration and electrolyte imbalance a danger?
Because electrolytes play an important role in homeostasis, the danger of
dehydration and an electrolyte balance can life threatening. If the
potassium or sodium levels are too high or low, it can interfere with the




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electrical activity within the heart causing it to have abnormal rhythms or
a myocardial infarction. Low blood pressure; confusion, disorientation and
renal failure can all be dangerous when there are dehydration and
electrolyte imbalances.
(Marieb. E, 2007)


7. How have the functions of the skin been impaired?
The functions that have been impaired are the ability to control body
temperature, the protective barrier against bacteria and pathogens, the
synthesising of vitamin D, the ability to maintain fluid, the ability to sweat
and the loss of senses to touch or pressure.
(Marieb. E, 2007)


8. How will the body try and repair the areas that have been burnt?
The body will try and repair the burns in 3 stages.
Inflammatory stage (1)
In this stage the body goes into physiologic defence, which can last from
2 to 5 days, which removes damaged cells, prevents further damage and
prepares the burn to heal. Blood vessels constrict and form a clot to
prevent further blood loss and damage. Inflammation then begins which
produces oedema, redness, tenderness, pain and heat around the area.
White blood cells then accumulate around the wound to prepare the
wound for healing.
Proliferation Stage (2)
This stage sees the epidermal cells beginning to activate and develop
granulation tissue and lasts between 3 to 24 days. The cells increase
across the wound and fibroblasts gather within the wound. The
fibroblasts begin to synthesise collagen-containing macrophages filling
the wound with connective tissue, slowly closing the top of the wound.




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Factors such as age and dietary needs can impair the healing process at
this stage.
Maturation Stage (3)
This final stage in wound healing the granulation tissue and fibroblasts
begin to decrease while the syntheses of collagen remains in balance,
providing greater strength to the wound. The epidermis begins to
regenerate itself. During this phase, ongoing collagen replacement helps
produce less scaring. Depending on the size or the severity of the wound,
the maturation stage can take more than a year.
(Crisp, J & Taylor,C. 2008)


9. What could impede the body from successfully achieving this?
Think of internal and external factors when you answer this.
The healing process may be impeded by factors s uch as
      Medications
      The severity of the wound
      Where the wound is located
      Age
      Diet/ Obesity
      General health or current medical conditions, eg, diabetes
      Stress
      Body temperature
      Lifestyle eg, smoking
      Infection


10. Mary undergoes debridement of the burns. What does this
mean?
Mary is undergoing the removal of the dead skin caused by her burns.
(Marieb. E, 2007)




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11. The burns were subsequently grafted with a split skin graft.
What part of the skin is used for this graft?
Split skin grafts can obtain skin from the lower back, lower legs and
abdomen. As Mary was placed in a bath, her skin most likely will be
obtained from the abdomen or lower back.
(Marieb. E, 2007)


Musculoskeletal System


Dorothy Nelson is 76 years old, was admitted to the emergency
department after a fall in her bathroom. She has a painful left hip,
her left leg was externally rotated and shortened. She was
commenced on IV fluids and medical management. Her x -ray
showed a displaced left fractured neck of femur. She has previously
been diagnosed as having osteoporosis.


1. You are the nurse allocated to care for Mrs Nelson, 3 days post
surgery to repair the fracture. List the types of documentation you
would expect to be in her patient record (chart) that would assist
you to care for her during your shift.
      Neurovascular chart
      Observation chart
      Progress notes
      Care plan
      Fluid balance chart
      Medication chart
      Medical history/allergies
      Admission Form




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      Mobility assessement


Cardiovascular system


1. Define hypertension and arteriosclerosis.
Hypertension - High blood pressure, which is caused by the higher
pressure of blood exerted on the artery walls
Arteriosclerosis – A thickening, hardening, narrowing or loss of elasticity
in arteries or blood vessels, which results in an interference in the
circulation of blood.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


2. How often are they related?
They are often related. An unbalanced diet, age, not enough exercise
and lifestyle choices, such as smoking, can produce both conditions.
Hypertension can cause arteriosclerosis by making the artery walls thick
and less elastic, which speeds up the forming of fatty deposits in blood
vessels. Hypertension can be a result of arteriosclerosis due to the artery
walls thickening and blood flow is restricted.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


3. Why is hypertension called the ‘silent killer’?
Hypertension is often called the silent killer because it often presents no
symptoms and can take up to 20 years to present itself. It is often not
picked up unless it is checked while being assessed for another
underlying problem.


4. Name three (3) changes in your lifestyle that might help to prevent
cardiovascular disease in old age.
Quit smoking, regular exercise and good nutrition.




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5. Undesirable clot formation can occur as a result of endothelial
damage due to arteriosclerosis. How does the body form
undesirable clots within intact blood vessels?
A homeostatic imbalance can cause increased platelets that form a
platelet plug within the intact blood vessel forms an undesirable clot
called a thrombus. A thrombus can occur over time due to the blood
pooling due to lack of mobility, local trauma or due to other factors such
as smoking, which can damage the smooth lining of the blood vessel.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


Respiratory System
At handover you are told a patient/client is cyanotic.


1. What would you expect to observe?
I would expect to observe a bluish colour to the skin and mucous
membranes due to insufficient oxygenated blood.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


2. Cyanosis is a sign of tissue hypoxia. Define what this means and
name three conditions where this could occur.
Tissue hypoxia means there is a decrease or deprivation of oxygen in a
region within or between the body, organs or body tissue.
Three conditions where this may occur is COPD (emphysema and
chronic bronchitis), Hypothermia, Heart failure
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


3. Describe the difference between a tracheostomy and
endotracheal intubation




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A tracheostomy intubation is a surgical opening of the trachea where a
tube is inserted through this opening to provide a passage for air to assist
in breathing.
The endotracheal intubation is where a tube is inserted through the
mouth and down into the trachea which also helps assist in breathing.


4. Why will a patient who is anaemic complain of shortness of
breath
Anaemia may cause shortness of breath due to the decrease of
haemoglobin in the blood (red blood cells), which carries oxygenated
blood from the lungs. Anaemia therefore reduces the ability to carry
oxygen to the body and organs.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


Paul is 15 years old, he has a known allergy to cashew nuts, but can
eat all other types of nuts with no ill effect. He is eating a chocolate
bar that contains mixed nuts. He complained of tingling around the
mouth and lips, developed a rapid swelling of the face, and
experienced difficulty breathing on inspiration, and within a few
minutes had an audible wheeze on expiration. The initial diagnosis
was asthma, but Paul was also treated for an allergic reaction.


5. What type of allergic reaction is suspected?
Paul may be experiencing an allergic response called anaphylaxis due to
the cashews or tree nuts that may have been present in the chocolate
bar. If left untreated can lead to anaphylactic shock, which can lead to
death.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


6. Why has this caused a problem with this breathing?




                                                                           8
This reaction causes the release of histamine into the body and the
bronchioles and smooth muscle tissue in the lungs constrict and making it
difficult to breathe. The immune system believes it is under threat and
over reacts to the substance by having an allergic reaction.
(Marieb. E, 2007)


Gastrointestinal System
1. Simon is 14 years old, admitted with severe abdominal pain and
fever, diagnosed with severe appendicitis. If he is left untreated
what would the result be?
Appendicitis is inflammation of the appendix. If left untreated, Simon’s
appendix may rupture and peritonitis may develop due to the appendix
wall breaking down and becoming necrotic causing an infection within the
abdominal lining. Septicaemia and death may occur if also left untreated.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


2. Why does a lack of fibre in the diet encourage the formation of
diverticula?
A diet that lacks fibre may cause pressure within the bowel and
constipation. The stools become hard and dry and difficult to pass.
Straining to pass hard stools may cause the lining of the muscles to
rupture and form pouches or pockets that bulge through the muscle
layers. This causes pain, bloating, bleeding, fever and discomfort and
leads to diverticulitis. Keeping the diet high in fibre will allow the stools to
remain soft and easy to pass allowing minimal damage to the muscle wall
within the bowel.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


3. Explain why obstruction in the common bile duct causes
interference with the digestion of some foods.




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Bile, which is an accumulation if bile salts, cholesterol, bilirubin and
electrolytes, is produced by the liver and stored in the gallbladder. Bile is
released into the duodenum via the bile ducts to aid in the break down of
fats, digestion and absorption of food. Food enters the stomach and then
onto the duodenum. Interference with food digestion can occur if there is
an obstruction in the common bile duct, the obstruction prevents the
proper breakdown of foods when it enters the duodenum preventing the
small intestine digesting lipids, carbohydrates and proteins properly. An
obstruction within the liver or gallbladder, such as a gallstone, may also
cause vomiting and pain which would also interfere with the proper
digestion of foods causing malnutrition.
(Marieb. E, 2007)


4. What nursing observations of their skin, faeces and urine would
support the diagnosis of an obstructed bile duct?
The skin will present a yellow colour, jaundice, due to increased levels of
bilirubin in the blood and an interruption to the drainage of bile. The skin
may also present with itchiness. The faeces will present as pale and the
urine dark due to the lack of the bile pigmentation. A urinalysis will also
diagnose the presence of bile within the urine.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


5. Where would these observations be recorded?
In their progress notes, fluid balance and bowel chart and observation
chart, care plan and urinalysis.


Nervous System


1. Adrenaline affects the sympathetic nervous system. Explain the
effect on blood pressure, heartbeat, breathing and the liver.




                                                                              10
Adrenaline is released into the bloodstream when you exercise,
experience fear, stress or when the body goes into a “fight or flight”
reaction. The large amounts of adrenalin cause the heart to beat faster
due to the extra supply of blood and oxygen. Blood pressure rises and
breathing becomes hard, fast and shallow. Adrenaline causes the liver to
release glycogen, rising blood sugar levels, which causes the release of
insulin by the pancreas.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


Urinary System


1. Explain why someone who is haemorrhaging ie. Has falling
systemic blood pressure/volume will have a decreased urine output.
Decreased urine output in someone who is haemorrhaging would occur
as the body has low blood volume, causing lo w blood pressure. The
body registers a drop in blood volume, which causes the heart to beat
harder and pump more blood. The veins narrow to return more blood to
the heart, blood therefore is decreased to the kidneys, where the
formation of urine is decreased so water is reabsorbed to increase the
volume of blood back into the arteries and veins, therefore decreasing the
urine output.
http://www.merck.com/mmhe/sec03/ch023/ch023a.html


Special Senses


1. Natalie is referred to an optometrist; her parents suspect a need
for glasses. Examination demonstrates that Natalie is myopic. Will
she need concave or convex lenses? Explain.
Myopia is due to the eyeball being oval shaped rather than round. Light
focuses in front of the retina instead of directly on the retina itself, causing




                                                                             11
short sightedness. Natalie will need concave lenses. Concave lenses
curve inwards allowing light rays to bend back to bring objects that are at
a distance into focus
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


2. Susan has been using her MP3 player constantly. Her doctor tests
her and tells her she has suffered extensive hearing loss.


3. What may have caused her deafness?
Listening to constant loud music for too long while wearing head phones.


4. Is it conductive or sensorineural deafness. Please define both.
It is sensorineural deafness
Sensorineural deafness is a form of decreased hearing or hearing loss
in which any sound via the external or middle ear that is conducted
normally is reduced due to damage in the inner ear or auditory nerve.
The hair cells in the cochlea become damaged due to factors such as
prolonged loud noise and ageing.
Conductive deafness is a form of hearing loss due to the loss of
sensitivity to sound, which is normally conducted through the external and
middle ear. Sound is affected before it reaches the cochlea and nerve
receptors of the inner ear. This type of hearing loss is can be associated
with fluid build up and the eardrums inability to pick up sound waves,
which can often be treated.
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


Case Study.


You have been provided with an admission form (next page). From
this you need to extract information, analyse it, participate in




                                                                          12
planning action to address the health issues and determine which
services would be implemented in the care of the client/patient.


Using the example discussed in class – musculoskeletal system to
assist you with the case study for your final assessment.


The scenario relates to Mr Alby Wright who has been admitted into
your ward. His patient history and admission is available for you to
review.


1.     Mr Wright’s admission states that he has CCF (congestive
cardiac failure). Clearly define CCF. What organs and which body
systems are affected by this disorder?
Congestive cardiac failure is an abnormal condition in where the heart’s
functions are impaired and results in insufficient blood being pumped to
the body’s organs properly. Because the ventricles cannot eject blood
effectively this causes a volume overload of blood, which begins to
congest and the organs may not get the blood they need.
The organs that are affected by this disorder are impaired left and right
ventricles and pulmonary arteries of the heart, the lungs, the kidneys and
stomach.
The cardiovascular, urinary, digestive and respiratory system are the
systems affected by this disorder.
http://www.buzzle.com/articles/congestive -heart-failure.html


2.     Give a brief overview of the function of the body systems
affected by this disorder.
The cardiovascular system, otherwise known as the blood-vascular or
the circulatory system, is composed of the heart, vessels (called arteries),
veins, and capillaries. The cardiovascular system functions to provide




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adequate circulation of blood around the body. The system helps with
the circulation of substances such as oxygen and nutrients and eliminates
waste products such as carbon dioxide.
The urinary system consists of two kidneys, two ureters, a bladder, and
nerves in the bladder and the urethra. The urinary system regulates
homeostasis by eliminating waste products such as toxins and drugs and
keeps the chemicals and water in balance by removing a waste product,
called urea, from the blood. It also helps regulate blood pressure,
electrolytes and red blood cell production.
The respiratory system consists of the nose, the pharynx, the larynx,
the trachea, lungs and bronchi. The function of the respiratory system is
to supply oxygenated blood to the body and organs and to allow the
exchange of gases, such as oxygen and carbon dioxide, as we breathe.
The lungs take in oxygen and then release the waste product, carbon
dioxide.
The digestive system consists of the mouth, the pharynx, the
esophageus, the stomach, the small and large intestine and the anus.
The function of the digestive system is to ingest food, break the food we
eat down physically and chemically into smaller parts so the body can
absorb the nutrients to nourish and provide energy. The body then rids of
indigestible waste through defecation.
(Marieb. E, 2007)


3.       Define the signs and symptoms of CCF, and explain why
these signs and symptoms occur.
Symptoms of CCF may include -
        Shortness of breath (dyspnoea), Fatigue and lethargy – due to the
         left side becoming congested and causes fatigue, lethargy and
         exertion even with little exercise.




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        Muscle weakness - due to insufficient blood supply and oxygen to
         the muscles.
        Confusion – due to abnormal levels of sodium
        Swelling in ankles, feet, hands or abdomen – due to the veins
         filling up with excess fluid.
        Rapid or irregular heartbeat - the heart needs to pump harder as it
         cannot pump blood at a normal rate.
        Chronic cough or wheezing - due to the fluid in the lungs and the
         lungs need to work harder.
        Ventricular failure – happens when it is left untreated
(Harris, P., Nagy,S. & Vardaxis, N. 2008).


4.       List the information taken on his admission that demonstrates
these signs and symptoms.
        Hypotension – low blood pressure, 90/40
        Cyanosis – lack of oxygen in the blood
        Pulse - 124
        Resps - 32
        Sats – 87%
        Dyspnea
        Confusion
        Age (77)


5.       Do you think his diabetes is related to his leg ulcer and
amputated left toe? Explain
Yes, because people with diabetes are already at an increased risk or
poor wound healing. Diabetes reduces blood circulation, which means
that wounds are slower to heal. People with diabetes have reduced




                                                                             15
sensations in their hands and feet; therefore do not notice as quickly any
injury or pain experienced straight away.
(Marieb. E, 2007)


6.      One of the medications he is taking is Lasix. What is the
action of Lasix?
Lasix, or otherwise known as Furosemide, is a diuretic for congestive
cardiac failure, renal failure, oedema associated with cardiac failure,
hepatic cirrhosis and high blood pressure. Lasix helps increase the
excretion potassium and plasma volume to allow the excretion of sodium,
chloride, calcium, magnesium, hydrogen and water within the urine.
Stops the reabsorption within the ascending loop of Henle of sodium and
chloride.
www.sanofi-aventis.ca/products/en/lasix.pdf


Which body systems are affected by it?
The Cardiovascular system
The Nervous system
The Integumentary system
The Digestive system
The Immune system
The Senses (eyes and ears)
The Urinary system
www.sanofi-aventis.ca/products/en/lasix.pdf


Explain why you think Mr Wright is ordered Lasix. Brief answer
only.
Mr Wright is ordered Lasix as it treats fluid build up (oedema) in people
with Congestive Cardiac Failure




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7.       List three conditions in Mr Wright’s relevant medical history
that are commonly associated with ageing.
        Arthritis NIDDM
        Diabetes
        Glaucoma
        Congestive Cardiac Failure


8.       Using Mr Wright’s admission history and assessment, list the
factors that may impact on his safety whilst in hospital and when he
returns home.
Factors that may impact on Mr Wrights safety at home or in hospital is his
        Mobility – at risk for falls
        Poor eyesight due to Glaucoma – risk for falls, unable to read
         medication labels properly
        Mental Confusion – may not understand simple instructions, may
         become forgetful with medication.
        Pain – may bring about depression and interfere with
         concentration.
        Weakness – may once again be prone to falls or impede mobility


9.       What other health professionals will be involved in his care
and what services can they provide for Mr Wright.
Blue Nurses – Assistance for high or low level care. They provide allied
health, personal care, domestic assistance, respite care and social
support.
Dietician – provide information and dietary needs for his diabetes.
HACC - Home help services that assist with house cleaning, shopping,
transport and assistance with meal preparation and washing or ironing.




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Local GP – assist with medication refills; refer to specialist if needed and
able to give education on services available.
MASS - Medical Aids Subsidy Scheme: provides assistance for aids and
equipment to eligible clients who have permanent or some disabilities.


10.    List the nursing documentation you would be expect to be
used in the care of Mr Wright.
Progress notes, fluid charts, bowel chart, weight/height/observation chart,
medication chart, pain chart, care plan, mobility chart/assessment, wound
chart, diabetic menu, allergy tags, admission form and medical history.




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